Clinical Endoscopy

Review

Artificial intelligence–driven decision-making after endoscopic resection for early gastric cancer: Katsuro Ichimasa, Masashi Misawa, Jimmy Bok Yan So, Fumiaki Ishibashi, Taishi Okumura, Yasuharu Maeda, Sho Suzuki, Tetsuo Nemoto, Khay Guan Yeoh, Kazuo Ohtsuka; Received April 16, 2026 Accepted June 30, 2026 Published online September 4, 2026; DOI: https://doi.org/10.5946/ce.2026.176 [Epub ahead of print]

Abstract PDF: Early gastric cancer (EGC) is increasingly managed by endoscopic resection (ER); however, lymph node metastasis (LNM), which occurs in approximately 5%–10% of cases, remains the key determinant for recommending additional gastrectomy. Current guideline-based strategies, including the eCura system, provide structured risk stratification but rely on categorical decision-making and may lead to overtreatment, as nearly 90% of patients undergoing additional surgery do not have LNM. Artificial intelligence (AI) has emerged as a promising tool for improving LNM predictions. Machine learning models using clinicopathological variables have demonstrated promising discriminatory performance (area under the curve, 0.69–0.94), often outperforming conventional scoring systems such as eCura. However, these approaches rely on predefined variables and are susceptible to interobserver variability in pathological assessments. Whole-slide image–based AI directly analyzes histopathological images, offering an objective and reproducible approach. Although evidence for EGC is limited, recent multicenter data have demonstrated promising results using routine hematoxylin and eosin–stained slides. Beyond the LNM risk, treatment decisions should also consider patient factors such as age, comorbidities, and competing mortality risks. AI is expected to support treatment decision-making by integrating these multidimensional factors, enabling more personalized and risk-adapted management after ER.

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Original Article

Clinicopathological and endoscopic features of Helicobacter pylori infection-negative gastric cancer in Japan: a retrospective study: Kentaro Imamura, Kenshi Yao, Satoshi Nimura, Takao Kanemitsu, Masaki Miyaoka, Yoichiro Ono, Toshiharu Ueki, Hiroshi Tanabe; Clin Endosc 2024;57(4):486-494. Published online March 22, 2024; DOI: https://doi.org/10.5946/ce.2023.258

Graphical Abstract Abstract PDF

Background
/Aims: Helicobacter pylori infection-negative gastric cancer (HPNGC) has not been systematically investigated in consecutive patients. Hence, this study aimed to investigate the clinicopathological and endoscopic features of HPNGC.
Methods
This single-center retrospective study selected participants from patients with gastric cancer who were treated at the Fukuoka University Chikushi Hospital between January 2013 and December 2021. Only patients diagnosed with HPNGC were enrolled, and their clinicopathological and endoscopic features were analyzed in detail.
Results
The prevalence of HPNGC in the present study was 2.6% (54/2112). The types of HPNGC observed in each gastric region were as follows: advanced gastric cancer was observed in the cardia; gastric adenocarcinoma of fundic-gland differentiation, gastric adenocarcinoma of foveolar-type presenting with whitish elevation and raspberry-like foveolar-type gastric adenocarcinoma, gastric adenocarcinoma arising in polyposis, and gastric adenocarcinoma with autoimmune gastritis were observed in the fundic gland region ranging from the gastric fornix to the gastric body; signet-ring cell carcinoma was observed in the gastric-pyloric transition region ranging from the lower gastric body to the gastric angle; and well-differentiated tubular adenocarcinoma with low-grade atypia was observed in the antrum.
Conclusions
This study revealed that tumors from each gastric region exhibited distinct macroscopic and histological types in HPNGC.

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Two cases of Helicobacter pylori negative mixed early gastric tumors: case report
Xingting Luo, Xiaoyuan Yi, Haixiao Fu, Liang Ye, Bin Huang, En Qin, Bin Li, Xuhua Xiao, Liyan Wang
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Incidence of Metachronous Gastric Cancer After Endoscopic Submucosal Dissection in Helicobacter pylori-uninfected Early Gastric Cancer
Yusuke Kawai, Junnosuke Hayasaka, Yorinari Ochiai, Junji Tanaka, Minoru Oda, Hiroshi Yamato, Yugo Suzuki, Yutaka Mitsunaga, Hiroyuki Odagiri, Akira Matsui, Shu Hoteya
Digestive Diseases and Sciences.2026;[Epub] CrossRef
Incarceration of the Afferent Loop into the Sutured Closed Mesenteric Defect after Gastrectomy Followed by Billroth-II Reconstruction for Gastric Cancer: Two Case Reports
Kiyotomi Maruyama, Tadaaki Shimizu, Kou Shimada, Arano Makino, Natsuhiro Morita, Tasuku Kawaguchi, Takahiro Amano, Tomoki Shirota, Kuniyuki Gomi, Motohiro Mihara
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Bo Zhang, Xue-Guo Sun, Qing-Juan He, Li Chen, Ti-Dong Shan
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Review

E-learning system to improve the endoscopic diagnosis of early gastric cancer: Kenshi Yao, Takashi Yao, Noriya Uedo, Hisashi Doyama, Hideki Ishikawa, Satoshi Nimura, Yuichi Takahashi; Clin Endosc 2024;57(3):283-292. Published online August 3, 2023; DOI: https://doi.org/10.5946/ce.2023.087

Abstract PDF

We developed three e-learning systems for endoscopists to acquire the necessary skills to improve the diagnosis of early gastric cancer (EGC) and demonstrated their usefulness using randomized controlled trials. The subjects of the three e-learning systems were “detection”, “characterization”, and “preoperative assessment”. The contents of each e-learning system included “technique”, “knowledge”, and “obtaining experience”. All e-learning systems proved useful for endoscopists to learn how to diagnose EGC. Lecture videos describing “the technique” and “the knowledge” can be beneficial. In addition, repeating 100 self-study cases allows learners to gain “experience” and improve their diagnostic skills further. Web-based e-learning systems have more advantages than other teaching methods because the number of participants is unlimited. Histopathological diagnosis is the gold standard for the diagnosis of gastric cancer. Therefore, we developed a comprehensive diagnostic algorithm to standardize the histopathological diagnosis of gastric cancer. Once we have successfully shown that this algorithm is helpful for the accurate histopathological diagnosis of cancer, we will complete a series of e-learning systems designed to assess EGC accurately.

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Takahiro Utsumi, Takahiro Horimatsu, Yoshitaka Nishikawa, Akira Teramoto, Daizen Hirata, Mineo Iwatate, Shinwa Tanaka, Nobuaki Ikezawa, Masaya Esaki, Shozo Osera, Chikara Ebisutani, Hiroaki Saito, Nobukazu Agatsuma, Yukiko Hiramatasu, Yuki Nakanishi, Yasu
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Mário Dinis-Ribeiro, Miguel Areia
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Gwang Ha Kim
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Comparing Raman Spectroscopy-Based Artificial Intelligence to High-Definition White Light Endoscopy for Endoscopic Diagnosis of Gastric Neoplasia: A Feasibility Proof-of-Concept Study
Tse Kiat Soong, Guo Wei Kim, Daryl Kai Ann Chia, Jimmy Bok Yan So, Jonathan Wei Jie Lee, Asim Shabbbir, Jeffrey Huey Yew Lum, Gwyneth Shook Ting Soon, Khek Yu Ho
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Case Report

Gastric cancer presenting with ramucirumab-related gastrocolic fistula successfully managed by colonic stenting: a case report: Hiroki Fukuya, Yoichiro Iboshi, Masafumi Wada, Yorinobu Sumida, Naohiko Harada, Makoto Nakamuta, Hiroyuki Fujii, Eikichi Ihara; Clin Endosc 2023;56(6):812-816. Published online May 11, 2023; DOI: https://doi.org/10.5946/ce.2022.117

Abstract PDF

We report a rare case of gastric cancer presenting with a gastrocolic fistula during ramucirumab and paclitaxel combination therapy that was successfully managed with colonic stenting. A 75-year-old man was admitted to our hospital with the chief complaint of melena. Esophagogastroduodenoscopy revealed a large ulcerated tumor in the lower stomach, judged by laparoscopy as unresectable (sT4bN1M0). After four cycles of first-line chemotherapy with S-1 plus oxaliplatin, the patient showed disease progression, and second-line therapy with ramucirumab and paclitaxel was started. At the end of the third cycle, the patient had gastric antral stenosis, which necessitated the placement of a gastroduodenal stent. When the patient complained of diarrhea 10 days later, esophagogastroduodenoscopy revealed a fistula between the greater curvature of the stomach and the transverse colon. The fistula was covered by double colonic stenting, with a covered metal stent placed within an uncovered metal stent, after which leakage from the stomach to the colon stopped.

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Shinji Tamada, Daiki Ikarashi, Naoki Yanagawa, Moe Toyoshima, Kenta Takahashi, Tomohiko Matsuura, Shigekatsu Maekawa, Renpei Kato, Mitsugu Kanehira, Ryo Takata, Wataru Obara
Frontiers in Oncology.2023;[Epub] CrossRef

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Original Articles

The pattern of metachronous recurrence after endoscopic submucosal dissection for gastric adenocarcinoma and dysplasias: Sunah Suk, Yeon Joo Seo, Dae Young Cheung, Han Hee Lee, Jin Il Kim, Soo-Heon Park; Clin Endosc 2023;56(4):470-478. Published online April 18, 2023; DOI: https://doi.org/10.5946/ce.2022.259

Graphical Abstract Abstract PDF

Background
/Aims: Metachronous recurrence incidences and risk factors following endoscopic submucosal dissection (ESD) for gastric adenocarcinoma and dysplasias were investigated.
Methods
Retrospective review of electronic medical records of patients who underwent gastric ESD at The Catholic University of Korea, Yeouido St. Mary’s Hospital.
Results
A total of 190 subjects were enrolled for analysis during the study period. The mean age was 64.4 years-old and the male sex occupied 73.7%. The mean observation period following ESD was 3.45 years. The annual incidence rate of metachronous gastric neoplasms (MGN) was about 3.96%. The annual incidence rate was 5.36% for the low-grade dysplasia group, 6.47% for the high-grade dysplasia group, and 2.74% for the EGC group. MGN was more frequent in the dysplasia group than in the EGC group (p<0.05). For those with MGN development, the mean time interval from ESD to MGN was 4.1 (±1.8) years. By using the Kaplan–Meier model, the estimated mean MGN free survival time was 9.97 years (95% confidence interval, 8.53–11.40) The histological types of MGN were not related to the primary histology types.
Conclusions
MGN following ESD developed in 3.96% annually and MGN was more frequent in the dysplasia group. The histological types of MGN did not correlate with those of primary neoplasm.

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Bile Reflux is a Risk Factor for Metachronous Development in Patients with Early Gastric Cancer
Hiroki Murai, Takuya Yamada, Yukihiro Kusumoto, Akane Namiki, Naoko Hayata, Akino Okamoto, Munehiro Ashida, Takafumi Tanimoto, Kohsaku Ohnishi, Tomohide Kurahashi, Motohiro Hirao, Atsushi Hosui, Naoki Hiramatsu
Endoscopy International Open.2026;[Epub] CrossRef
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Meixi Gong, Xuanbing Li, Ruijun Xin, Yuansen Ma, Xiaomei Wu, Yan Zhao, Yu Sun, Bo Zhu
Annals of Medicine.2025;[Epub] CrossRef
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Advances in Clinical Medicine.2024; 14(02): 4201. CrossRef
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Dong Chan Joo, Gwang Ha Kim
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Seunghan Lee, Soo-Jeong Cho, Hyunsoo Chung, Bokyung Kim, Mi Jin Oh, Yun Suk Na, Jun Hee Lee, Jiyoon Kim, Sang Gyun Kim
Gut and Liver.2024; 18(6): 992. CrossRef

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Exploring quality indicators for the detection of Helicobacter pylori-naïve gastric cancer: a cross-sectional nationwide survey: Fumiaki Ishibashi, Toshiaki Hirasawa, Hiroya Ueyama, Yohei Minato, Sho Suzuki; Clin Endosc 2023;56(4):460-469. Published online April 4, 2023; DOI: https://doi.org/10.5946/ce.2022.167

Graphical Abstract Abstract PDF Supplementary Material

Background
/Aims: Diagnosis of Helicobacter pylori-naïve gastric cancer (HPNGC) is becoming increasingly important. This study aimed to explore the quality indicators for HPNGC detection.
Methods
We conducted a cross-sectional, nationwide, web-based survey of gastrointestinal endoscopists in Japan. In addition to questions about the number of HPNGC cases detected in a year and basic information, the questionnaire also consisted of 28 questions: (1) 18 about HPNGC awareness, (2) six about diagnostic proactiveness, and (3) four about interest in HPNGC.
Results
Valid responses were obtained from 712 endoscopists. The Japan Gastroenterological Endoscopy Society-certified endoscopists had a significantly higher HPNGC detection rate than the nonspecialists (0.42% vs. 0.32%, respectively; p=0.008). The results of the multiple regression analysis showed that Japan Gastroenterological Endoscopy Society certification and high awareness and interest scores were independent predictors of the HPNGC detection rate (p=0.012, p<0.001, p=0.024, respectively). Principal component analysis showed that the endoscopists who attended conferences for collecting information on HPNGC had a higher level of awareness.
Conclusions
To improve the detection of HPNGC, it is necessary to increase the awareness of the disease. It is hoped that relevant societies will play an important role in endoscopists’ education.

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Clinico-epidemiological Characteristics of Helicobacter pylori-naïve Undifferentiated Gastric Cancer
Yuichiro Kemmoto, Fumiaki Ishibashi, Toshiaki Hirasawa, Ryu Tanaka, Tomohiro Kawakami, Kentaro Mochida, Yuka Yanai, Chizu Yokoi, Yuko Hayashi, Shun-ichiro Ozawa, Koji Uraushihara, Yohei Minato, Hiroyuki Nakanishi, Hiroya Ueyama, Mikinori Kataoka, Yuzo Toy
Internal Medicine.2026; 65(7): 951. CrossRef
Prevalence and Incidence of Gastric Cancer Among Helicobacter pylori–Naïve Individuals in Japan: A Systematic Review and Meta‐Analysis
Chikamasa Ichita, Chika Kusano, Takuji Gotoda, Yasuhiro Hagiwara, Yuichiro Kemmoto, Ran Li, Ayaka Takasu, Yutaka Matsuyama, Manami Inoue, Nobutake Yamamichi, Hideki Ishikawa, Fumiaki Ishibashi
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Fumiaki Ishibashi, Kosuke Okusa, Yoshitaka Tokai, Toshiaki Hirasawa, Tomohiro Kawakami, Kentaro Mochida, Yuka Yanai, Chizu Yokoi, Yuko Hayashi, Shun-ichiro Ozawa, Koji Uraushihara, Yohei Minato, Hiroyuki Nakanishi, Hiroya Ueyama, Mikinori Kataoka, Yuzo To
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Case Report

Gastric wall abscess after endoscopic submucosal dissection: Seung Jung Yu, Sang Heon Lee, Jun Sik Yoon, Hong Sub Lee, Sam Ryong Jee; Clin Endosc 2023;56(1):114-118. Published online January 3, 2022; DOI: https://doi.org/10.5946/ce.2021.203

Abstract PDF

Gastric wall abscess, a localized form of phlegmonous gastritis, is a rare complication of endoscopic resection. We report the first case of gastric wall abscess developing after endoscopic submucosal dissection in Korea. A 72-year-old woman visited our clinic to receive treatment for gastric adenoma. The patient successfully underwent endoscopic submucosal dissection with no complications. The final diagnosis was well-differentiated tubular adenocarcinoma. We performed follow-up endoscopy 10 weeks later and found a large subepithelial lesion on the posterior wall of the gastric antrum. Abdominal computed tomography revealed hypodense wall thickening and a 5 cm heterogenous multilobular mass in the submucosal layer of the gastric antrum. Submucosal invasion with mucin-producing adenocarcinomas could therefore not be excluded. The patient agreed to undergo additional gastrectomy due to the possibility of a highly malignant lesion. The final diagnosis was acute suppurative inflammation with the formation of multiple abscesses in the mural layers and omentum. The patient was discharged with no complications.

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A case of gastric sinus abscess, a rare disease successfully treated by endoscopic incision and drainage
Weijing Wang, Teng Wang, Duo Wei, Rong Zhang
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Guo-Li Cao, Ze-Ming Chen, Xiao-Dong Li, Xi-Qiu Yu
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Original Articles

Efficacy and Safety of Endoscopic Submucosal Dissection for Superficial Gastric Neoplasms: A Latin American Cohort Study: Fernando Palacios-Salas, Harold Benites-Goñi, Luis Marin-Calderón, Paulo Bardalez-Cruz, Jorge Vásquez-Quiroga, Edgar Alva-Alva, Bryan Medina-Morales, Jairo Asencios-Cusihuallpa; Clin Endosc 2022;55(2):248-255. Published online November 12, 2021; DOI: https://doi.org/10.5946/ce.2021.192

Abstract PDF

Background
/Aims: Endoscopic submucosal dissection (ESD) is the preferred technique for treating early gastric cancer (EGC). However, very few studies have been conducted in South America. This study aimed to assess the efficacy and safety of ESD for EGC.
Methods
We analyzed data from a prospective cohort from 2013 to 2020. A total of 152 superficial gastric neoplasms that fulfilled the absolute or expanded criteria for ESD were included. Outcomes were en bloc, R0, and curative resection rates, incidence of adverse events, and length of procedure.
Results
The age of the enrolled patients was 68.4±11.3 years. The number of included patients based on the absolute and expanded indications was 150 and 2, respectively. En bloc, R0, and curative resections were achieved in 98.0%, 96.1%, and 89.5% of the cases, respectively. Bleeding and perforation were reported in 5.9% and 6.6% of the cases, respectively. Histopathological examination revealed lowgrade dysplasia, high-grade dysplasia, well-differentiated adenocarcinoma, and poorly differentiated adenocarcinoma in 13, 20, 117, and 2 cases, respectively.
Conclusions
Our study shows that ESD performed by properly trained endoscopists in reference centers is safe and effective, with comparable therapeutic outcomes to those reported in the Eastern series.

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Chilean Association of Digestive Endoscopy (ACHED) guidelines for the detection of early gastric cancer and surveillance of gastric premalignant conditions in high-risk populations
Gonzalo Latorre, Alberto Espino, Raúl Araya, Matías Arteaga, Harold Benites-Goñi, María Ester Bufadel, Dacio Cabrera-Hinojosa, Roberto Candia, Julian Cordero, Oscar Corsi, Pablo Cortés, Felipe Donoso, Fabian Emura, Carolina Heredia, Daniel Martínez, Rodri
Gastroenterología y Hepatología.2026; 49(3): 502633. CrossRef
Chilean Association of Digestive Endoscopy (ACHED) guidelines for the detection of early gastric cancer and surveillance of gastric premalignant conditions in high-risk populations
Gonzalo Latorre, Alberto Espino, Raúl Araya, Matías Arteaga, Harold Benites-Goñi, María Ester Bufadel, Dacio Cabrera-Hinojosa, Roberto Candia, Julian Cordero, Oscar Corsi, Pablo Cortés, Felipe Donoso, Fabian Emura, Carolina Heredia, Daniel Martínez, Rodri
Gastroenterología y Hepatología (English Edition).2026; 49(3): 502633. CrossRef
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Henrik Maltzman, Peter Elbe, Martin Jeremiasen, Masami Omae, Francisco Baldaque-Silva, Erik von Seth, Mats Lindblad, Fredrik Klevebro
Scandinavian Journal of Surgery.2026;[Epub] CrossRef
Outcomes and validity of risk stratification tools for endoscopic submucosal dissection of early gastric cancer in Western Australia
Ciaran Judge, Abir Halder, Puraskar Pateria, Tzeng Khor, Niroshan Muwanwella, Marcus Chin, Krish Ragunath
JGH Open.2024;[Epub] CrossRef
Disección submucosa endoscópica en cáncer gástrico temprano indiferenciado: evaluación de los primeros casos y análisis de su aplicación como indicación absoluta en Perú
Fernando Palacios-Salas, Luis Marin-Calderón, Juan Chirinos-Vega, Paulo Bardalez-Cruz, Patricia Valera-Luján, Dacio Cabrera-Hinojosa, Harold Benites-Goñi
Revista de Gastroenterología del Perú.2024; 44(4): 333. CrossRef
Short-Term and Long-Term Outcomes of Liver Cirrhosis in Gastric Neoplasm Patients Undergoing Endoscopic Submucosal Dissection
Xu-Rui Liu, Lian-Shuo Li, Fei Liu, Zi-Wei Li, Xiao-Yu Liu, Wei Zhang, Dong Peng
Journal of Laparoendoscopic & Advanced Surgical Techniques.2023; 33(7): 640. CrossRef
Endoscopic submucosal dissection for early gastric cancer: It is time to consider the quality of its outcomes
Gwang Ha Kim
World Journal of Gastroenterology.2023; 29(43): 5800. CrossRef
Endoscopic diagnosis of early gastric cancer
Dong Chan Joo, Gwang Ha Kim
Journal of the Korean Medical Association.2022; 65(5): 267. CrossRef
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Eun Jeong Gong, Chang Seok Bang
Journal of the Korean Medical Association.2022; 65(5): 284. CrossRef

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Clinical Impact of Different Reconstruction Methods on Remnant Gastric Cancer at the Anastomotic Site after Distal Gastrectomy: Kei Matsumoto, Shinwa Tanaka, Takashi Toyonaga, Nobuaki Ikezawa, Mari Nishio, Masanao Uraoka, Tomoatsu Yoshihara, Hiroya Sakaguchi, Hirofumi Abe, Tetsuya Yoshizaki, Madoka Takao, Toshitatsu Takao, Yoshinori Morita, Hiroshi Yokozaki, Yuzo Kodama; Clin Endosc 2022;55(1):86-94. Published online August 13, 2021; DOI: https://doi.org/10.5946/ce.2021.084

Abstract PDF Supplementary Material: Background
/Aims: The anastomotic site after distal gastrectomy is the area most affected by duodenogastric reflux. Different reconstruction methods may affect the lesion characteristics and treatment outcomes of remnant gastric cancers at the anastomotic site. We retrospectively investigated the clinicopathologic and endoscopic submucosal dissection outcomes of remnant gastric cancers at the anastomotic site.
Methods
We recruited 34 consecutive patients who underwent endoscopic submucosal dissection for remnant gastric cancer at the anastomotic site after distal gastrectomy. Clinicopathology and treatment outcomes were compared between the Billroth II and non-Billroth II groups.
Results
The tumor size in the Billroth II group was significantly larger than that in the non-Billroth II group (22 vs. 19 mm; p=0.048). More severe gastritis was detected endoscopically in the Billroth II group (2 vs. 1.33; p=0.0075). Moreover, operation time was longer (238 vs. 121 min; p=0.004) and the frequency of bleeding episodes was higher (7.5 vs. 3.1; p=0.014) in the Billroth II group.
Conclusions
Compared to remnant gastric cancers in non-Billroth II patients, those in the Billroth II group had larger lesions with a background of severe remnant gastritis. Endoscopic submucosal dissection for remnant gastric cancers in Billroth II patients involved longer operative times and more frequent bleeding episodes than that in patients without Billroth II.

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183 Download

Clinical Outcomes and Adverse Events of Gastric Endoscopic Submucosal Dissection of the Mid to Upper Stomach under General Anesthesia and Monitored Anesthetic Care: Jong-In Chang, Tae Jun Kim, Na Young Hwang, Insuk Sohn, Yang Won Min, Hyuk Lee, Byung-Hoon Min, Jun Haeng Lee, Poong-Lyul Rhee, Jae J Kim; Clin Endosc 2022;55(1):77-85. Published online July 5, 2021; DOI: https://doi.org/10.5946/ce.2021.002

Abstract PDF Supplementary Material

Background
/Aims: Endoscopic submucosal dissection (ESD) of gastric tumors in the mid-to-upper stomach is a technically challenging procedure. This study compared the therapeutic outcomes and adverse events of ESD of tumors in the mid-to-upper stomach performed under general anesthesia (GA) or monitored anesthesia care (MAC).
Methods
Between 2012 and 2018, 674 patients underwent ESD for gastric tumors in the midbody, high body, fundus, or cardia (100 patients received GA; 574 received MAC). The outcomes of the propensity score (PS)-matched (1:1) patients receiving either GA or MAC were analyzed.
Results
The PS matching identified 94 patients who received GA and 94 patients who received MAC. Both groups showed high rates of en bloc resection (GA, 95.7%; MAC, 97.9%; p=0.68) and complete resection (GA, 81.9%; MAC, 84.0%; p=0.14). There were no significant differences between the rates of adverse events (GA, 16.0%; MAC, 8.5%; p=0.18) in the anesthetic groups. Logistic regression analysis indicated that the method of anesthesia did not affect the rates of complete resection or adverse events.
Conclusions
ESD of tumors in the mid-to-upper stomach at our high-volume center had good outcomes, regardless of the method of anesthesia. Our results demonstrate no differences between the efficacies and safety of ESD performed under MAC and GA.

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Histological Architecture of Gastric Epithelial Neoplasias That Showed Absent Microsurface Patterns, Visualized by Magnifying Endoscopy with Narrow-Band Imaging: Kenta Chuman, Kenshi Yao, Takao Kanemitsu, Takashi Nagahama, Masaki Miyaoka, Haruhiko Takahashi, Kentaro Imamura, Rino Hasegawa, Toshiharu Ueki, Hiroshi Tanabe, Seiji Haraoka, Akinori Iwashita; Clin Endosc 2021;54(2):222-228. Published online November 24, 2020; DOI: https://doi.org/10.5946/ce.2020.090

Abstract PDF

Background
/Aims: The objective of this study was to elucidate the histological structure of the absent microsurface patterns (MSPs) that were visualized by magnifying endoscopy with narrow-band imaging (M-NBI).
Methods
The study included consecutive gastric epithelial neoplasias for which M-NBI findings and histological findings could be compared on a one-to-one basis. The lesions were classified as absent MSPs and present MSPs based on the findings obtained using M-NBI. Of the histopathological findings for each lesion that corresponded to M-NBI findings, crypt opening densities, crypt lengths, crypt opening diameters, intercrypt distances, and crypt angles were measured and compared.
Results
Thirty-six lesions were included in the analysis; of these, 17 lesions exhibited absent MSP and 19 lesions exhibited present MSP. Comparing the histological measurements for absent MSPs vs. present MSPs, median crypt opening density was 0.9 crypt openings/mm vs. 4.8 crypt openings/mm (p<0.001), respectively. The median crypt length, median crypt opening diameter, median intercrypt distance, and median crypt angle were 80.0 μm vs. 160 μm (p<0.001), 40.0 μm vs. 44.2 μm (p=0.09), 572.5 μm vs. 166.7 μm (p<0.001), and 21.6 degrees vs. 15.5 degrees (p<0.001), respectively.
Conclusions
Histological findings showed that lesions exhibiting absent MSPs had lower crypt opening density, shorter crypt length, greater intercrypt distance, and larger crypt angle.

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Focused Review Series: Application of Artificial Intelligence in GI Endoscopy

Lesion-Based Convolutional Neural Network in Diagnosis of Early Gastric Cancer: Hong Jin Yoon, Jie-Hyun Kim; Clin Endosc 2020;53(2):127-131. Published online March 30, 2020; DOI: https://doi.org/10.5946/ce.2020.046

Abstract PDF

Diagnosis and evaluation of early gastric cancer (EGC) using endoscopic images is significantly important; however, it has some limitations. In several studies, the application of convolutional neural network (CNN) greatly enhanced the effectiveness of endoscopy. To maximize clinical usefulness, it is important to determine the optimal method of applying CNN for each organ and disease. Lesion�-based CNN is a type of deep learning model designed to learn the entire lesion from endoscopic images. This review describes the application of lesion-based CNN technology in diagnosis of EGC.

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Review

Clinical Practice Guideline for Endoscopic Resection of Early Gastrointestinal Cancer: Chan Hyuk Park, Dong-Hoon Yang, Jong Wook Kim, Jie-Hyun Kim, Ji Hyun Kim, Yang Won Min, Si Hyung Lee, Jung Ho Bae, Hyunsoo Chung, Kee Don Choi, Jun Chul Park, Hyuk Lee, Min-Seob Kwak, Bun Kim, Hyun Jung Lee, Hye Seung Lee, Miyoung Choi, Dong-Ah Park, Jong Yeul Lee, Jeong-Sik Byeon, Chan Guk Park, Joo Young Cho, Soo Teik Lee, Hoon Jai Chun; Clin Endosc 2020;53(2):142-166. Published online March 30, 2020; DOI: https://doi.org/10.5946/ce.2020.032

Abstract PDF Supplementary Material

Although surgery was the standard treatment for early gastrointestinal cancers, endoscopic resection is now a standard treatment for early gastrointestinal cancers without regional lymph node metastasis. High-definition white light endoscopy, chromoendoscopy, and image-enhanced endoscopy such as narrow band imaging are performed to assess the edge and depth of early gastrointestinal cancers for delineation of resection boundaries and prediction of the possibility of lymph node metastasis before the decision of endoscopic resection. Endoscopic mucosal resection and/or endoscopic submucosal dissection can be performed to remove early gastrointestinal cancers completely by en bloc fashion. Histopathological evaluation should be carefully made to investigate the presence of risk factors for lymph node metastasis such as depth of cancer invasion and lymphovascular invasion. Additional treatment such as radical surgery with regional lymphadenectomy should be considered if the endoscopically resected specimen shows risk factors for lymph node metastasis. This is the first Korean clinical practice guideline for endoscopic resection of early gastrointestinal cancer. This guideline was developed by using mainly de novo methods and encompasses endoscopic management of superficial esophageal squamous cell carcinoma, early gastric cancer, and early colorectal cancer. This guideline will be revised as new data on early gastrointestinal cancer are collected.

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Original Articles

Quality Indicators for the Detection of Helicobacter pylori-Negative Early Gastric Cancer: A Retrospective Observational Study: Fumiaki Ishibashi, Konomi Kobayashi, Keita Fukushima, Ryu Tanaka, Tomohiro Kawakami, Junko Kato, Kazuaki Sugihara; Clin Endosc 2020;53(6):698-704. Published online March 13, 2020; DOI: https://doi.org/10.5946/ce.2019.203

Abstract PDF

Background
/Aims: While Helicobacter pylori (HP)-negative gastric cancer is frequently reported, little is known about the predictors for detecting HP-negative early gastric cancer (EGC). We aimed to evaluate the predictors for the detection of HP-negative EGC.
Methods
We retrospectively reviewed 13,477 consecutive asymptomatic cases where upper endoscopy was performed by nine physicians from April 2017 to March 2019 and analyzed the detection rate of high-risk lesions (HRLs), including EGC, tubular adenoma, and lymphoma, according to the status of HP infection. The observation time was corrected for multiple regression analyses.
Results
For all physicians, the average observation time for screening HP-eradicated and -naïve patients was shorter than that for screening HP-positive patients (p<0.05). Multiple regression analyses revealed that the observation time in the three groups was an independent predictor for detecting HRLs in HP-eradicated patients (p=0.03106, 0.01263, and 0.02485, respectively), while experience of endoscopy was an independent predictor for detecting HRLs in HP-naïve patients (p=0.02638).
Conclusions
While observation time during screening endoscopy was a quality indicator for detecting HRLs in HP-eradicated patients, experience of endoscopy was a quality indicator for detecting HRLs in HP-naïve patients.

Citations

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Endoscopic Factors that Can Predict Histological Ulcerations in Early Gastric Cancers: Jaesin Lee, Byung-Wook Kim, Cheal Wung Huh, Joon Sung Kim, Lee-So Maeng; Clin Endosc 2020;53(3):328-333. Published online January 7, 2020; DOI: https://doi.org/10.5946/ce.2019.133

Abstract PDF

Background
/Aims: Predicting histological ulceration in early gastric cancer (EGC) during endoscopic examination is crucial for endoscopists deciding on the treatment modality. The aim of this study was to investigate the endoscopic factors that can predict histological ulcerations in EGCs.
Methods
We retrospectively analyzed patients who underwent endoscopic submucosal dissection (ESD) for EGC. Clinical features and endoscopic characteristics of EGC such as location, histological differentiation, longest diameter, tumor morphology, mucosal break, converging fold, color change, and surface irregularity were reviewed. Histological ulceration was defined based on ESD specimens.
Results
A total of 633 EGC lesions from 613 patients were included and histological ulcerations were found in 90 lesions (14.2%). Presence of converging folds, tumor morphology, and color changes on endoscopic examination were related to histological ulceration in the univariate analysis and converging folds along with color changes were statistically significant factors in the multivariate analysis. Kaplan–Meier analysis showed that patients with histological ulcerations in EGCs tended to have higher marginal recurrence rates.
Conclusions
Mucosal breaks are not equivalent to histological ulcerations. Rather, the existence of converging folds and color changes during endoscopic examination suggest histological ulcerations. Endoscopists should consider these factors when they decide the treatment modality for EGCs.

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Anas Zayad, Yousef Yahia, Prem Chandra, Ibrahim Obeidat, Mohamad Safieh, Sadi Alnakhala, Husam Saffo
International Journal of General Medicine.2026; Volume 19: 1. CrossRef
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Risk Factors and Clinical Outcomes of Non-Curative Resection in Patients with Early Gastric Cancer Treated with Endoscopic Submucosal Dissection: A Retrospective Multicenter Study in Korea: Si Hyung Lee, Min Cheol Kim, Seong Woo Jeon, Kang Nyeong Lee, Jong Jae Park, Su Jin Hong, Korean Society of Gastrointestinal Endoscopy Endoscopic Submucosal Dissection Research Group; Clin Endosc 2020;53(2):196-205. Published online October 25, 2019; DOI: https://doi.org/10.5946/ce.2019.123

Abstract PDF

Background
/Aims: The purpose of this study was to investigate the risk factors and long-term clinical outcomes of non-curative resection (NCR) in a large-scale patient population.
Methods
We retrospectively analyzed the clinical data of 3,094 patients who underwent endoscopic submucosal dissection (ESD) of early gastric cancer from March 2005 to March 2018 at 13 institutions in Korea. We analyzed the risk factors for NCR and the survival between patients with curative resection and those with NCR with no additional treatment.
Results
The NCR rate was 21.4% (661/3,094). In multivariate regression analysis, the risk factors affecting NCR with ESD were old age, undifferentiated tumor, tumor location in the upper body, tumor size ≥2 cm, and presence of an ulcer. In Cox proportional hazard regression analysis, tumor size ≥2 cm, submucosal invasion, positive horizontal margin, and lymphovascular invasion were risk factors for local recurrence. In Kaplan-Meier analysis, there was no statistically significant difference in the overall survival between the two groups (log-rank p=0.788). However, disease-specific survival was significantly lower in the NCR group (log-rank p=0.038).
Conclusions
Clinicians should be aware of the risk factors for NCR and local recurrence after ESD for early gastric cancer, and should consider providing additional treatment after NCR.

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348 Download
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Review

Assessment of Endoscopic Gastric Atrophy according to the Kimura-Takemoto Classification and Its Potential Application in Daily Practice: Duc Trong Quach, Toru Hiyama; Clin Endosc 2019;52(4):321-327. Published online July 22, 2019; DOI: https://doi.org/10.5946/ce.2019.072

Abstract PDF

The assessment of endoscopic gastric atrophy (EGA) according to the Kimura-Takemoto classification has been reported to correlate well with histological assessment. Although agreement among beginner endoscopists was less than that among experienced endoscopists, it has been shown that agreement level could markedly improve and remained stable after proper training. Several cohort studies have consistently shown that the severity of EGA at baseline is significantly associated with the presence of advanced precancerous gastric lesions and gastric cancer, as well as the development of gastric cancer in future. Patients with moderate-to-severe EGA still have high risk of gastric cancer even after successful Helicobacter pylori eradication and should be candidates for gastric cancer surveillance. The assessment of EGA, therefore, could be used as a preliminary tool to identify individuals at high risk for gastric cancer. In this paper, we review the agreement on mucosal atrophy assessment between the Kimura-Takemoto classification and histology as well as the potential application of this endoscopic classification to identify precancerous gastric lesions and gastric cancer in daily practice.

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Original Article

Immunohistochemical Expression of Epithelial-Mesenchymal Transition Markers in Early Gastric Cancer: Cancer Tissue versus Noncancer Tissue: Hee Jae Jung, Su Jin Hong, Shin Hee Kim; Clin Endosc 2019;52(5):464-471. Published online May 22, 2019; DOI: https://doi.org/10.5946/ce.2018.181

Abstract PDF

Background
/Aims: Epithelial-mesenchymal transition (EMT) is a developmental process, wherein the epithelial cells show reduced intercellular adhesions and acquire migratory fibroblastic properties. EMT is associated with downregulation in epithelial marker expression, abnormal translocation of E-cadherin, and upregulation in mesenchymal marker expression. Here, we investigated the immunohistochemical (IHC) expression of EMT markers in early gastric cancer (EGC) between cancer and noncancer tissues.
Methods
Tissue samples were prospectively obtained from 19 patients with EGC that underwent endoscopic submucosal dissection (ESD). We compared the expression level of transforming growth factor (TGF)-β, vascular endothelial growth factor (VEGF), E-cadherin, α-smooth muscle actin (α-SMA), and vimentin between cancer and noncancer tissues using IHC. Among the 19 patients, 15 patients had follow-up biopsy at 3 months after ESD for EGC.
Results
Cancer tissues presented higher values of EMT mesenchymal markers (α-SMA/vimentin/TGF-β/VEGF) than the noncancerous tissues (p<0.05) that were significantly low after ESD (p<0.05). No significant correlation was reported for tumor location and initial Helicobacter pylori infection.
Conclusions
The mesenchymal expression of EMT markers was higher in the cancerous tissues than in the noncancer tissues.

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Focused Review Series: Endoscopic Submucosal Dissection for Undifferentiated-Type Early Gastric Cancer

Is Radical Surgery Necessary for All Patients Diagnosed as Having Non-Curative Endoscopic Submucosal Dissection?: Si Hyung Lee, Byung Sam Park; Clin Endosc 2019;52(1):21-29. Published online January 30, 2019; DOI: https://doi.org/10.5946/ce.2019.014

Abstract PDF

If a lesion does not meet the expanded indication criteria for treatment with endoscopic therapy for early gastric cancer or does not have a positive resection margin, it is regarded as suitable for non-curative resection. Non-curative resection is closely related to the risk of local recurrence, lymph node metastasis, and poor prognosis. If the result is confirmed as non-curative resection, additional treatment should be considered depending on the risks of residual tumor, local recurrence, and lymph node metastasis. As lymphatic invasion is the most important risk factor of recurrence and poor prognosis, surgical treatment should be considered if lymphatic invasion is present. If patients are not suitable for additional surgery owing to old age or coexisting severe disease, close surveillance can be an alternative treatment option.

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Focused Review Series: Current Status of Image-Enhanced Endoscopy (IEE)

Linked Color Imaging and Blue Laser Imaging for Upper Gastrointestinal Screening: Hiroyuki Osawa, Yoshimasa Miura, Takahito Takezawa, Yuji Ino, Tsevelnorov Khurelbaatar, Yuichi Sagara, Alan Kawarai Lefor, Hironori Yamamoto; Clin Endosc 2018;51(6):513-526. Published online November 2, 2018; DOI: https://doi.org/10.5946/ce.2018.132

Abstract PDF

White light imaging (WLI) may not reveal early upper gastrointestinal cancers. Linked color imaging (LCI) produces bright images in the distant view and is performed for the same screening indications as WLI. LCI and blue laser imaging (BLI) provide excellent visibility of gastric cancers in high color contrast with respect to the surrounding tissue. The characteristic purple and green color of metaplasias on LCI and BLI, respectively, serve to increase the contrast while visualizing gastric cancers regardless of a history of Helicobacter pylori eradication.
LCI facilitates color-based recognition of early gastric cancers of all morphological types, including flat lesions or those in an H. pylori-negative normal background mucosa as well as the diagnosis of inflamed mucosae including erosions. LCI reveals changes in mucosal color before the appearance of morphological changes in various gastric lesions. BLI is superior to LCI in the detection of early esophageal cancers and abnormal findings of microstructure and microvasculature in close-up views of upper gastrointestinal cancers. Excellent images can also be obtained with transnasal endoscopy. Using a combination of these modalities allows one to obtain images useful for establishing a diagnosis. It is important to observe esophageal cancers (brown) using BLI and gastric cancers (orange) surrounded by intestinal metaplasia (purple) and duodenal cancers (orange) by LCI.

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Case Reports

A Rare Case of Lymph Node Metastasis from Early Gastric Cancer: Takaaki Yoshikawa, Yoshio Kadokawa, Masaya Ohana, Akihisa Fukuda, Hiroshi Seno; Clin Endosc 2019;52(4):369-372. Published online October 5, 2018; DOI: https://doi.org/10.5946/ce.2018.130

Abstract PDF

Gastric cancers that fulfill the Japanese criteria for curative endoscopic resection show a low risk of lymph node (LN) metastasis. Here, we report a case of LN metastasis from early gastric cancer that fulfilled the curative criteria. A 74-year-old Japanese woman was referred to our hospital for treatment of early gastric cancer identified at the site of a hyperplastic polyp that had been diagnosed 10 years prior to presentation. Contrast-enhanced computed tomography did not show any lymphadenopathy and laparoscopy-assisted distal gastrectomy was performed. Histopathological examination revealed a predominantly moderately differentiated adenocarcinoma that measured 15 mm in size and was confined to the mucosa. However, a single metastatic regional LN was observed. A few cancer cells showed positive staining for alpha-fetoprotein. It should be noted that early gastric cancer can be accompanied by LN metastasis even if it fulfills the criteria for curative endoscopic resection.

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Alpha-fetoprotein-producing intramucosal gastric cancer found during examination of metastatic lymph nodes
Tomoya Sano, Takahiro Toyokawa, Mami Yoshii, Yuichiro Miki, Tatsuro Tamura, Shigeru Lee, Kiyoshi Maeda
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Hayemin Lee, Mi Ryeong Park, Junhyun Lee
Annals of Surgical Treatment and Research.2025; 109(2): 81. CrossRef

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Blue Laser Imaging with a Small-Caliber Endoscope Facilitates Detection of Early Gastric Cancer: Haruo Takahashi, Yoshimasa Miura, Hiroyuki Osawa, Takahito Takezawa, Yuji Ino, Masahiro Okada, Alan Kawarai Lefor, Hironori Yamamoto; Clin Endosc 2019;52(3):273-277. Published online August 14, 2018; DOI: https://doi.org/10.5946/ce.2018.100

Abstract PDF

Conventional endoscopy often misses early gastric cancers with minimal red discoloration because they cannot be distinguished from inflamed mucosa. We treated a patient with a small early gastric cancer that was difficult to diagnose using conventional endoscopy. Conventional endoscopy using a small-caliber endoscope showed only subtle red discoloration of the gastric mucosa. However, blue laser imaging showed a clearly discolored area measuring 10 mm in diameter around the red lesion, which was distinct from the surrounding inflamed mucosa. Irregular vessels on the tumor surface (suspicious for early gastric cancer) were observed even with small-caliber endoscopy. Biopsy revealed a well-moderately differentiated tubular adenocarcinoma, and endoscopic submucosal dissection was performed. Histopathological examination of the specimen confirmed well-moderately differentiated adenocarcinoma localized to the mucosa with slight depression compared to the surrounding mucosa, consistent with the endoscopic findings. This small early gastric cancer became clearly visible with blue laser imaging using small-caliber endoscopy.

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Jodie Chuan Yue Foo, Rabia'tul A'dawiah, Keertana Vinod Ram, Nuraini Zailani, Derrick Yong, Jayakumar Perumal, Malini Olivo, U. S. Dinish
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Diagnostic performance of blue laser imaging for early detection of gastric cancer: A systematic review and meta-analysis
Mohammed Rifat Shaik, Andrew Canakis, Nishat Anjum Shaik, Shivanand Bomman, Dushyant Singh Dahiya, Emily Gorman, Mohammad Bilal, Saurabh Chandan
Indian Journal of Gastroenterology.2024; 43(5): 976. CrossRef
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Tsevelnorov Khurelbaatar, Yoshimasa Miura, Hiroyuki Osawa, Yuji Ino, Takahito Takezawa, Chihiro Iwashita, Yoshie Nomoto, Masato Tsunoda, Takashi Ueno, Haruo Takahashi, Manabu Nagayama, Hisashi Fukuda, Alan Kawarai Lefor, Hironori Yamamoto
Endoscopy International Open.2022; 10(05): E644. CrossRef
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Kohei Oka, Naoto Iwai, Takashi Okuda, Tasuku Hara, Yutaka Inada, Toshifumi Tsuji, Toshiyuki Komaki, Junichi Sakagami, Yuji Naito, Keizo Kagawa, Yoshito Itoh, Fabiana Zingone
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Appropriate Color Enhancement Settings for Blue Laser Imaging Facilitates the Diagnosis of Early Gastric Cancer with High Color Contrast
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Review

Metachronous Gastric Cancer Following Curative Endoscopic Resection of Early Gastric Cancer: Seiichiro Abe, Ichiro Oda, Takeyoshi Minagawa, Masau Sekiguchi, Satoru Nonaka, Haruhisa Suzuki, Shigetaka Yoshinaga, Amit Bhatt, Yutaka Saito; Clin Endosc 2018;51(3):253-259. Published online September 18, 2017; DOI: https://doi.org/10.5946/ce.2017.104

Abstract PDF

This review article summarizes knowledge about metachronous gastric cancer (MGC) occurring after curative endoscopic resection (ER) of early gastric cancer (EGC), treatment outcomes of patients who developed MGC, and efficacy of Helicobacter pylori eradication to prevent MGC. The incidence of MGC following curative ER increases over time and is higher than in patients undergoing gastrectomy. Increasing age and multifocal EGC are independent risk factors for developing MGC. An MGC following curative ER is usually a small (<20 mm) and differentiated intramucosal cancer. Most MGC lesions are found at an early stage on semiannual or annual surveillance endoscopy and are successfully treated by further ER, with excellent long-term outcomes. Eradication of H. pylori may reduce the risk of MGC following ER of EGC, but further prospective studies with long-term outcomes are required. Surveillance endoscopy following gastric ER should be continued indefinitely, due to the risk of MGC even after successful H. pylori eradication. Risk stratification and tailored endoscopic surveillance schedules need to be developed.

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Case Report

A Rare Case of Early Gastric Cancer Combined with Underlying Heterotopic Pancreas: Jung Bin Yoon, Bong Eun Lee, Dae Hwan Kim, Do Youn Park, Hye Kyung Jeon, Dong Hoon Baek, Gwang Ha Kim, Geun Am Song; Clin Endosc 2018;51(2):192-195. Published online August 31, 2017; DOI: https://doi.org/10.5946/ce.2017.055

Abstract PDF

Heterotopic pancreas in the stomach is usually asymptomatic and benign. Here, we presented a rare case of an early gastric cancer overlying a heterotopic pancreas. A 48-year-old woman underwent esophagogastroduodenoscopy, which revealed a subepithelial mass measuring 2.0×1.5 cm on the gastric antrum with a 1-cm erosive erythematous discoloration on the surface. A biopsy specimen showed moderately differentiated tubular adenocarcinoma. Endosonography showed a heterogeneous hypoechoic mass measuring 1.3×0.6 cm, with indistinct margins in the second and third layers of the gastric wall; anechoic tubular structures within the mass were suggestive of heterotopic pancreas. Distal gastrectomy was performed, which confirmed an early gastric cancer confined to the mucosa, and a separate underlying heterotopic pancreas. Although heterotopic pancreas is most likely benign, careful endoscopic observation of the mucosal surface is necessary to avoid overlooking a coincident early gastric cancer.

Citations

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Focused Review Series: Endoscopic Accessories Used for ESD

Future Development of Endoscopic Accessories for Endoscopic Submucosal Dissection: Jae-Young Jang; Clin Endosc 2017;50(3):242-249. Published online May 31, 2017; DOI: https://doi.org/10.5946/ce.2017.073

Abstract PDF

Endoscopic submucosal dissection (ESD) has recently been accepted as a standard treatment for patients with early gastric cancer (EGC), without lymph node metastases. Given the rise in the number of ESDs being performed, new endoscopic accessories are being developed and existing accessories modified to facilitate the execution of ESD and reduce complication rates. This paper examines the history underlying the development of these new endoscopic accessories and indicates future directions for the development of these accessories.

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Reviews

How to Interpret the Pathological Report before and after Endoscopic Submucosal Dissection of Early Gastric Cancer: Dae Young Cheung, Soo-Heon Park; Clin Endosc 2016;49(4):327-331. Published online July 25, 2016; DOI: https://doi.org/10.5946/ce.2016.082

Abstract PDF

Possible lymph node metastasis (LNM) and residual cancer are major concerns in endoscopic submucosal dissection (ESD) for early gastric cancer. To reduce the risk of LNM and cancer recurrence, the proper indications for ESD should be considered. Histology, size, depth of invasion, and presence of ulceration should be thoroughly evaluated before proceeding with ESD. However, with incomplete information, discrepancies often arise between the pathological diagnosis based on the forceps biopsy and that based on the totally resected specimen. In addition, the presence of lymphovascular involvement and histological homogeneity can be clarified only after ESD. If the pathological diagnosis changes after ESD, we should reevaluate the curativeness and reformulate the goal of treatment. Additional surgery is a reasonable strategy for non-curative ESD, but a patient’s other health conditions should also be considered. It is simple to read pathological reports before and after ESD, but it can be a complicated art to interpret the report and formulate an optimal approach. In this review, various considerations regarding the pathological diagnosis will be discussed.

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Borrmann Type 4 Advanced Gastric Cancer: Focus on the Development of Scirrhous Gastric Cancer: Kyoungwon Jung, Moo In Park, Sung Eun Kim, Seun Ja Park; Clin Endosc 2016;49(4):336-345. Published online July 25, 2016; DOI: https://doi.org/10.5946/ce.2016.057

Abstract PDF

Early diagnosis of Borrmann type 4 advanced gastric cancer (AGC) is very important for improving the prognosis of AGC patients. Because there is no definite mass in most cases of Borrmann type 4 AGC, its accurate diagnosis via endoscopy requires an understanding of its pathogenesis and developmental process. Moreover, many people confuse linitis plastica (LP) type gastric cancer (GC), scirrhous GC, and Borrmann type 4 AGC. To distinguish each of these cancers, knowledge of their endoscopic and pathological differences is necessary, especially for LP type GCs in the developmental stage. In conclusion, diagnosis of pre-stage or latent LP type GC before progression to typical LP type GC requires the detection of IIc-like lesions in the fundic gland area. It is also crucial to identify any abnormalities such as sclerosis of the gastric wall and hypertrophy of the mucosal folds during endoscopy.

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Treatment Strategy after Incomplete Endoscopic Resection of Early Gastric Cancer: Sang Gyun Kim; Clin Endosc 2016;49(4):332-335. Published online July 20, 2016; DOI: https://doi.org/10.5946/ce.2016.069

Abstract PDF

Endoscopic resection of early gastric cancer is defined as incomplete when tumor cells are found at the resection margin upon histopathological examination. However, a tumor-positive resection margin does not always indicate residual tumor; it can also be caused by tissue contraction during fixation, by the cautery effect during endoscopic resection, or by incorrect histopathological mapping. Cases of highly suspicious residual tumor require additional endoscopic or surgical resection. For inoperable patients, argon plasma coagulation can be used as an alternative endoscopic treatment. Immediately after the incomplete resection or residual tumor has been confirmed by the pathologist, clinicians should also decide upon any additional treatment to be carried out during the follow-up period.

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Focused Review Series: Image Enhanced Endoscopy

Clinical Application of Magnifying Endoscopy with Narrow-Band Imaging in the Stomach: Kenshi Yao; Clin Endosc 2015;48(6):481-490. Published online November 30, 2015; DOI: https://doi.org/10.5946/ce.2015.48.6.481

Abstract PDF

Magnifying endoscopy with narrow-band imaging (M-NBI) can visualize superficial microanatomies in the stomach. The normal morphology of the microanatomy visualized by M-NBI differs according to the part of the stomach. The gastric fundic glandular mucosa appears as a regular honeycomb-like subepithelial capillary network (SECN) pattern with a regular collecting venule pattern and regular oval crypt opening with circular marginal crypt epithelium (MCE) pattern. The gastric pyloric glandular mucosa displays a regular coil-shaped SECN pattern and regular polygonal or curved MCE pattern. For a diagnosis of early gastric cancer using M-NBI, the vessel plus surface classification system was developed. This system is clinically useful for the differential diagnosis of focal gastritis and small depressed cancer and for determining the horizontal extent of early gastric cancer for successful endoscopic resection. Advantages of M-NBI over conventional endoscopic imaging techniques with white light include accurate diagnosis and cost effectiveness. This technique is a breakthrough in the endoscopic diagnostic field.

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Review

Improving the Endoscopic Detection Rate in Patients with Early Gastric Cancer: Hee Seok Moon; Clin Endosc 2015;48(4):291-296. Published online July 24, 2015; DOI: https://doi.org/10.5946/ce.2015.48.4.291

Abstract PDF

Endoscopists should ideally possess both sufficient knowledge of the endoscopic gastrointestinal disease findings and an appropriate attitude. Before performing endoscopy, the endoscopist must identify several risk factors of gastric cancer, including the patient's age, comorbidities, and drug history, a family history of gastric cancer, previous endoscopic findings of atrophic gastritis or intestinal metaplasia, and a history of previous endoscopic treatments. During endoscopic examination, the macroscopic appearance is very important for the diagnosis of early gastric cancer; therefore, the endoscopist should have a consistent and organized endoscope processing technique and the ability to comprehensively investigate the entire stomach, even blind spots.

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Case Report

Liver Metastasis of Early Gastric Cancer with Mixed Histology after Endoscopic Submucosal Dissection: Yang Hee Han, Jong Kyu Park, Jun Sung Kwon, Young Don Kim, Woo Jin Jeong, Sang Jin Lee, Koon Hee Han, Gab Jin Cheon; Clin Endosc 2015;48(3):247-250. Published online May 29, 2015; DOI: https://doi.org/10.5946/ce.2015.48.3.247

Abstract PDF

The Japanese Classification of Gastric Carcinoma histologically classifies endoscopically resected gastric cancer into differentiated and undifferentiated types according to the presence or absence of tubular structures on histology. The former includes papillary adenocarcinoma and tubular types, and the latter includes poorly differentiated adenocarcinoma, signet ring cell carcinoma and mucinous adenocarcinoma. However, gastric cancer sometimes contains a mixture of differentiated and undifferentiated components, and the clinical outcomes of the histological mixture are unknown, especially following endoscopic resection of early gastric cancer (EGC). This case was within the guideline indications for endoscopic submucosal resection (ESD), although it contained a partly signet ring cell carcinoma component; it recurred after 19 months with multiple lymph node and liver metastases. This case shows that additional surgical resection after ESD should be performed for patients with any mixed signet ring cell component, even in mild or moderately differentiated EGC.

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Original Article

Clinical Outcomes of Argon Plasma Coagulation Therapy for Early Gastric Neoplasms: Kyu Young Kim, Seong Woo Jeon, Hea Min Yang, Yu Rim Lee, Eun Jeong Kang, Hyun Seok Lee, Sung Kook Kim; Clin Endosc 2015;48(2):147-151. Published online March 27, 2015; DOI: https://doi.org/10.5946/ce.2015.48.2.147

Abstract PDF

Background/Aims

Argon plasma coagulation (APC) has some merits in the treatment of gastric neoplasms including a shorter operative time and fewer complications compared with endoscopic mucosal resection or endoscopic submucosal dissection. However, there are few reports on the outcomes of gastric neoplasms treated using APC. The aim of this study was to evaluate APC in the treatment of early gastric neoplasms in terms of clinical efficacy, safety, and local recurrence.

Methods

We enrolled 28 patients who received APC therapy at the Kyungpook National University Hospital between May 2007 and April 2013. Clinical outcomes were analyzed.

Results

The median follow-up period was 24.8 months (range, 2 to 78). Among the 28 lesions treated using the APC procedure, tumor recurrence was encountered in seven lesions (25.0%). Recurrence was found in 50% (5/10) of single APC cases and 11% (2/18) of rescue APC cases. The mean time to recurrence was 16.1 months (range, 2 to 78). There were no serious APC-related complications such as perforation, bleeding, or infection.

Conclusions

APC therapy can be a useful treatment with a favorable safety profile for patients with early gastric neoplasms. However, further studies are necessary to determine the long-term prognosis of patients undergoing this treatment.

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Special Issue Article of IDEN 2013

Long-Term Outcome of Extended Endoscopic Submucosal Dissection for Early Gastric Cancer with Differentiated Histology: Ji Yong Ahn, Hwoon-Yong Jung; Clin Endosc 2013;46(5):463-466. Published online September 30, 2013; DOI: https://doi.org/10.5946/ce.2013.46.5.463

Abstract PDF

Endoscopic mucosal resection was introduced in the 1990s, and endoscopic submucosal dissection (ESD) in 2003. Currently, ESD is becoming the main procedure for the resection of early gastric cancer (EGC) and is leading to the development of extended indications for endoscopic resection. Many reports showed that the endoscopic and oncologic outcome of endoscopic treatment in the extended indication group was acceptable in terms of curability and safety. Especially, ESD showed better results to remove extended indication EGCs with relatively high resection rate and low local recurrence rate. However, more long-term follow-up data are needed for clinical application of the extended criteria of ESD due to the risk of lymph node metastasis. We should also keep in mind that accurate diagnosis, characterization of the lesion, and proper appreciation of technical aspects are most essential in therapeutic endoscopy.

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Reviews

The Role of Endoscopic Ultrasonography in T Staging: Early Gastric Cancer and Esophageal Cancer: Jin Woong Cho; Clin Endosc 2013;46(3):239-242. Published online May 31, 2013; DOI: https://doi.org/10.5946/ce.2013.46.3.239

Abstract PDF

While a number of diagnostic methods have been developed, endoscopic ultrasound (EUS) still takes the most important role in the preoperative evaluation of esophageal cancer. EUS can detect lesions of all esophageal cancer and can accurately perform T staging. In a recent meta-analysis of EUS in esophageal cancer, the sensitivity and specificity of EUS on esophageal cancer were 81.6% and 99.4% in T1, 81.4% and 96.3% in T2, 91.4% and 94.4% in T3, and 92.4% and 97.4% in T4, respectively. The use of EUS can reduce unnecessary surgeries and lead to apply proper treatments to patients. The advance of endoscopic submucosal dissection have necessitated the presurgical detection of early cancer lesions without lymph node metastasis. Understanding the practical meanings of images shown by EUS is important to decide patients for whom endoscopic treatments can be effective. In early gastric cancer, EUS can accurately predict mucosal and SM1 (invasion into the submucosal layer of less than 500 µm from muscularis mucosa) lesions, which are considered as good indications for endoscopic treatments.

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Expert Review of Gastroenterology & Hepatology.2021; 15(3): 255. CrossRef
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The Clinical Significance and Management of Noncurative Endoscopic Resection in Early Gastric Cancer: Jun Heo, Seong Woo Jeon; Clin Endosc 2013;46(3):235-238. Published online May 31, 2013; DOI: https://doi.org/10.5946/ce.2013.46.3.235

Abstract PDF

Nowadays, endoscopic mucosal resection or endoscopic submucosal dissection has shown effectiveness equivalent to that of gastrectomy and has emerged as a popular technique for curative treatment of gastric cancer. However, noncurative resection or resection beyond the indication may lead to lymphatic and extended organ metastasis resulting in loss of the opportunity for full recovery. Therefore, it is an important issue to decide the range of curative resection in the endoscopic resection field. Furthermore, management of noncurative endoscopic resection in early gastric cancer is also important. The most favorable treatment after noncurative resection would be surgery. However, other noninvasive treatments such as argon plasma coagulation, additional endoscopic resection and close observation for recurrence are thought to be the optional treatments after the noncurative resection. In the future, prospective research studies and observations are expected to verify the effectiveness of noninvasive treatments.

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Risk stratification and management of non-curative resection after endoscopic submucosal dissection for early gastric cancer
Jae Pil Han, Su Jin Hong, Hee Kyung Kim, Yun Nah Lee, Tae Hee Lee, Bong Min Ko, Joo Young Cho
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Kwang An Kwon, Il Ju Choi, Eun Young Kim, Seok Ho Dong, Ki Baik Hahm
Clinical Endoscopy.2013; 46(3): 203. CrossRef

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Original Article

Early Gastric Cancer-Like Advanced Gastric Cancer versus Advanced Gastric Cancer-Like Early Gastric Cancer: Hyun Sik Park, Sun-Young Lee, Sung Noh Hong, Jeong Hwan Kim, In-Kyung Sung, Hyung Seok Park, Chan Sup Shim, Choon Jo Jin; Clin Endosc 2013;46(2):155-160. Published online March 31, 2013; DOI: https://doi.org/10.5946/ce.2013.46.2.155

Abstract PDF

Background/Aims

Improvements in the endoscopic evaluation and management of gastric cancer have made it possible to determine the depth of invasion during endoscopic examination. The aim of this study was to elucidate the differences between early gastric cancer (EGC) that resembles advanced gastric cancer (AGC) and AGC that resembles EGC.

Methods

We retrieved cases of EGC-like AGC and AGC-like EGC from consecutive gastric cancers that had been completely resected. The endoscopic diagnoses and clinicopathological findings were analyzed.

Results

AGC-like EGCs were located mainly in the distal part of the stomach, whereas EGC-like AGCs were located mainly in the proximal part of the stomach (p<0.001). Sixty percent of AGC-like EGCs were moderately differentiated adenocarcinomas, while 64% of EGC-like AGCs were poorly differentiated adenocarcinomas (p=0.015). According to Lauren's classification, 68% of AGC-like EGCs were intestinal type, whereas 71% of EGC-like AGCs were diffuse type (p=0.020).

Conclusions

AGC-like EGCs predominate in the distal part of the stomach, while EGC-like AGCs predominate in the proximal part. When evaluating the depth of a gastric cancer, care should be taken not to underestimate measurements in proximal gastric cancers since they tend to be poorly-differentiated adenocarcinomas, in Lauren's diffuse type, and invade deeper than their endoscopic appearance might suggest.

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PLOS ONE.2019; 14(9): e0223284. CrossRef
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Special Issue Articles of IDEN 2012

Estimation by Gross Findings in Early Gastric Cancer: Sang Gyun Kim; Clin Endosc 2012;45(3):245-247. Published online August 22, 2012; DOI: https://doi.org/10.5946/ce.2012.45.3.245

Abstract PDF

Endoscopic resection has been accepted as both minimally invasive and curative treatment modality for early gastric cancer (EGC). The widely accepted indication of endoscopic resection for EGC is small sized, differentiated mucosal cancer in which the risk of lymph node metastasis is negligible. Tumor size can be measured by conventional endoscopy, and chromoendoscopy, magnifying endoscopy, narrow band imaging, autofluorescence imaging can also be helpful for accurate estimation of tumor size. Pretreatment tumor histology can be assessed with endoscopic biopsy, and also be measured by confocal endomicroscopy (so called "virtual biopsy"). Although endoscopic ultrasonography may be helpful for the assessment of tumor depth in EGC, the accurate assessment of tumor depth can be performed by the typical findings in the conventional endoscopy, by which treatment modality can be decided according to the depth of tumor invasion.

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Abdullah S. Shaikh, Emmanuel Almanza Huante, Mehran Taherian, Andres E. Quesada, Elias J. Jabbour, Selvi Thirumurthi
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Case Report

Successful Treatment of Early Gastric Cancer Adjacent to a Fundal Varix by Endoscopic Submucosal Dissection and Endoscopic Cyanoacrylate Therapy: Yeon Soo Kim, Won Young Cho, Joo Young Cho, So Young Jin; Clin Endosc 2012;45(2):169-173. Published online June 30, 2012; DOI: https://doi.org/10.5946/ce.2012.45.2.169

Abstract PDF

Endoscopic submucosal dissection (ESD) was developed for the en bloc resection of large early gastrointestinal neoplasms. A disadvantage of ESD is its technical difficulty, which requires advanced skills and is associated with a higher rate of complications. Endoscopic variceal obturation (EVO) using cyanoacrylate has emerged as the initial treatment of choice for acute gastric variceal bleeding. This procedure achieves hemostasis in 90% of cases. A 52-year-old patient with Child A alcoholic liver cirrhosis presented with early gastric cancer in the cardia and type 1 isolated gastric varices in the fundus. The two lesions were so close together that treatment was not easy. The lesions were managed successfully with a combination of ESD and EVO using cyanoacrylate.

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Original Article

Clinical Outcomes of Endoscopic Submucosal Dissection for Undifferentiated or Submucosal Invasive Early Gastric Cancer: Pyung Gohn Goh, Hyun Yong Jeong, Min Jung Kim, Hyuk Soo Eun, Hye Jin Kim, Eui Sik Kim, Yun Jeung Kim, Soo Youn Lee, Hee Seok Moon, Eaum Seok Lee, Seok Hyun Kim, Jae Kyu Sung, Byung Seok Lee; Clin Endosc 2011;44(2):116-122. Published online December 31, 2011; DOI: https://doi.org/10.5946/ce.2011.44.2.116

Abstract PDF

Background/Aims

Early gastric cancer (EGC) that is undifferentiated or shows submucosal invasion has not been generally accepted as an indication for endoscopic treatment. But recently, experiences with endoscopic submucosal dissection (ESD) for undifferentiated EGC or submucosal invasive (SM) EGC have increased. The aim of this study was to evaluate clinical outcomes of ESD for EGC with undifferentiation or submucosal invasion.

Methods

Between August 2005 and August 2009, among 210 EGCs treated using ESD at our hospital, 18 lesions were diagnosed as undifferentiated gastric cancer and 41 as SM gastric cancer. A retrospective analysis was done on the medical records of these patients.

Results

Mean follow-up periods were 19.39±11.2 months. During the follow-up period, local recurrence was noted in 4 lesions. Local recurrence rates of the EGC groups (group 1, mucosal cancer with undifferentiation; group 2, SM cancer with differentiation; group 3, SM cancer with undifferentiation) were 10%, 4.5%, and 50%, respectively. Groups 1 and 2 were not significantly different in local recurrence rates compared to the mucosal cancer with differentiation group (p=0.061, p=0.125, respectively). The undifferentiated EGC group was significantly lower in curability using ESD than the differentiated EGC group (55.6% vs. 89.6%, p=0.000). The curability of the SM EGC group was lower than the mucosal EGC group (36.6% vs. 98.9%).

Conclusions

Complete resection using ESD is difficult in undifferentiated and SM gastric cancers. SM cancer with undifferentiation should be treated immediately by salvage operation. For mucosal cancer with undifferentiation or SM cancer with differentiation, one should consider careful short-term follow-up.

Citations

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Local Recurrence of EGC after ESD: Sang Hun Lee, M.D., Jin Hwan Jung, M.D., Jun Ho Song, M.D., Jeong Ho Kim, M.D., Dae Young Cheung, M.D., Jin Il Kim, M.D., Soo Heon Park, M.D. and Jae Kwang Kim, M.D.; Korean J Gastrointest Endosc 2011;42(2):90-93. Published online February 28, 2011

Abstract PDF: Endoscopic mucosal resection is not accepted as an alternative to surgery for treating EGC of the undifferentiated histologic type because of the relatively higher probability of lymph node metastasis with the endoscopic procedure. The recently developed endoscopic submucosal dissection (ESD) techniques have made en-bloc resection of large intramucosal or ulcerated lesions feasible, but the procedure's therapeutic indications are limited to EGC without lymph node metastasis. If we could define a subgroup of patients who have undifferentiated EGC with a low-risk of lymph node metastasis, then the application of ESD would be possible instead of surgery. ESD also allows precise histologic assessment of resected specimens and it may prevent residual disease and local recurrence. We report on a case that poorly differentiated adenocarcinoma was curatively removed by ESD, but cancer recurrence was detected in the lamina propria of the post ESD scar without lymph node metastasis or intraluminal lesions three years after the ESD. (Korean J Gastrointest Endosc 2011;42:90-93)

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A Case of an Exoluminal Gastrointestinal Stromal Tumor That Was Confused with a Metastatic Lymph Node in Early Gastric Cancer: Jung Soo Park, M.D., Hyojin Park, M.D., Jong Won Kim, M.D.*, Sun Och Yoon, M.D.^†, Hyung Soon Park, M.D., Jie-Hyun Kim, M.D., Young Hoon Yoon, M.D. and Eun Na Cho, M.D.; Korean J Gastrointest Endosc 2010;41(5):285-289. Published online November 30, 2010

Abstract PDF: Gastric adenocarcinoma may coexist with tumors of other histological types. The synchronous occurrence of gastric adenocarcinoma and gastrointestinal stromal tumor (GIST) has rarely been reported in the literature. It is still not known whether such an association represents an incidental coexistence or indicates a similar pathogenesis in the simultaneous development of tumors of different histological types. Here we report a case of an exoluminal GIST that was confused with a metastatic lymph node in early gastric cancer. (Korean J Gastrointest Endosc 2010;41:285-289)

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Systemic Sarcoidosis Associated with Early Gastric Cancer: Kyung-Hun Lee, M.D., Kyoung-Oh Kim, M.D., Yu Jin Kim, M.D., Jae Hyung Lee, M.D., Kwang Pyo Son, M.D.,Kyung Rim Huh, M.D., Cheol Hee Park, M.D. and Jong Hyeok Kim, M.D.; Korean J Gastrointest Endosc 2010;40(6):374-377. Published online June 30, 2010

Abstract PDF: For a potentially malignant lymphadenopathy, it is clinically important to distinguish between metastasis of a primary tumor and a benign lesion such as systemic sarcoidosis or sarcoid reaction. We describe here a case of systemic sarcoidosis that was associated with early gastric cancer. A patient was found to have early gastric cancer (EGC) during routine clinical examination. The chest radiography demonstrated bilateral hilar lymphadenopathy and further examination showed that he had multiple lymphadenopathies. We diagnosed systemic sarcoidosis with EGC because of the elevated serum ACE-I, the chest CT findings and the pathological analysis. We performed endoscopic submucosal dissection (ESD) for EGC, and there was no local recurrence and distant metastasis for eighteen months. These findings suggest that the possibility of systemic sarcoidosis should be considered in cases with established malignancy and multiple lymphadenopathies. (Korean J Gastrointest Endosc 2010;40:374-377)

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Recurrent Gastric Cancer at the Duodenal Stump after Billroth II Subtotal Gastrectomy: Jeong Guil Lee, M.D., Hwa Young Lee, M.D., Seon Mi Jin, M.D., Il Park, M.D., Sang Jong Lee, M.D., Woo Joong Kim, M.D. and Yoon Hee Lee, M.D.*; Korean J Gastrointest Endosc 2010;40(4):266-269. Published online April 30, 2010

Abstract PDF: Many studies have shown that gastric stump cancer develops after distal gastrectomy, particularly after Billroth II reconstruction. But, recurrent cancer at the duodenal stump following Billroth II type distal gastrectomy for gastric cancer is extremely rare. We report a case of duodenal stump cancer in a 64-year-old man underwent Billroth II distal gastrectomy. (Korean J Gastrointest Endosc 2010;40: 266-269)

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Gastric Lymphoepithelioma-like Carcinoma Diagnosed and Treated by Endoscopic Submucosal Dissection: Review of the Literature: Jun Ho Cho, M.D., Wan Sik Lee, M.D., Kyoung Rok Lee, M.D., Hye Kyong Jeong, M.D., Sung Bum Cho, M.D., Young Eun Joo, M.D., Sung Kyu Choi, M.D. and Jong Sun Rew, M.D.; Korean J Gastrointest Endosc 2010;40(4):256-260. Published online April 30, 2010

Abstract PDF: Gastric lymphoepithelioma-like carcinoma (LELC) is a rare neoplasm of the stomach that features undifferentiated carcinoma mixed with lymphoid stroma, and it invariably has a good prognosis. Most gastric LELCs have been linked to Epstein-Barr virus (EBV) infection. We experienced a case of a patient with gastric LELC. A 57 years old female patient was found to have shallow irregular ulcerative lesion on the gastric antrum. Although repetitive endoscopic biopsy didn't yield any cancer, early gastric cancer (EGC) was strongly suspected. Endoscopic submucosal dissection (ESD) was performed for establishing the correct diagnosis and curatively resecting the lesion. The pathology revealed gastric LELC with vertical invasion to the submucosa. No remnant cancer and no lymph node metastasis were noted after surgery following ESD. Here, we are reporting on a case of gastric ELEC along with reviewing the relevant literature. We believe this is the first case of gastric ELEC that was successfully diagnosed and managed by ESD. (Korean J Gastrointest Endosc 2010;40:256-260)

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Dieulafoy's Lesion Coexisting with Early Gastric Cancer: Yong Soo Ahn, M.D., Hyeuk Park, M.D., Young Jun Hwang, M.D., Hong Myong Jung, M.D., Jang Sik Mun, M.D., Bo Hyun Myoung, M.D., Do Hyun Kim, M.D. and Ho Dong Kim, M.D.; Korean J Gastrointest Endosc 2009;39(3):158-161. Published online September 30, 2009

Abstract PDF: Dieulafoy's lesion is an uncommon cause of gastrointestinal (GI) bleeding, but can be associated with massive, life-threatening GI bleeding. This lesion is an isolated protruding vessel of the submucosal artery associated with a small mucosal defect and normal surrounding mucosa. Although this lesion can occur throughout the GI tract (esophagus, stomach, duodenum, colon, rectum, etc), it has been rarely reported elsewhere than the stomach. Especially, there have been no reports of Dieulafoy lesion coexistent with early gastric cancer in Korea. We report the successful application of endoscopic hemoclipping for the treatment of a very rare Dieulafoy lesion coexistent with early gastric cancer. (Korean J Gastrointest Endosc 2009;39:158-161)

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A Survey on the Indication for Endoscopic Submucosal Dissection in Early Gastric Cancer: Chang Kyun Lee, M.D., Il-Kwun Chung, M.D., Joo Young Cho, M.D., Jae J. Kim, M.D.*, Hoon Jai Chun, M.D.^†, Hyun Yong Jeong, M.D.^‡ and Sang Young Seol, M.D.^§; Korean J Gastrointest Endosc 2009;39(2):78-84. Published online August 30, 2009

Abstract PDF: Background
/Aims: Endoscopic submucosal dissection (ESD) has become a widely accepted method for treating early gastric cancer (EGC) in Korea. However, there is not an established guideline for indications of ESD. The objective of this study was to assess the current status and practice patterns regarding indications for ESD in Korea.
Methods
A 17-item questionnaire about indications for ESD in EGC was presented to the participants of the 2^nd joint symposium of the Gastrointestinal Pathology Study Group of the Korean Society of pathologists. Keypad-based anonymous voting was carried out and the entire process was recorded.
Results
Endoscopic submucosal dissection for EGC fulfilling the classical indications was widely accepted as an effective therapeutic strategy comparable to surgery (114/115, agreement 99.5%). In our survey, Japanese extended criteria for ESD was still debated (70/111, 63.6%), but most respondents had performed ESD selectively in EGC corresponding to the extended criteria (105/109, 96.3%). They agreed that the current criteria for ESD would possibly require a revision considering various clinical indicators.
Conclusions
Our survey shows that there is still no consensus about indications for ESD in EGC. Therefore, more clinical outcome data with a long-term follow-up are needed to establish evidence-based consensus and guidelines for ESD indications in Korea. (Korean J Gastrointest Endosc 2009;39:78-84)

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Endoscopic Submucosal Dissection of Early Gastric Cancer That Occurred in a Patient with Chronic Myelogenous Leukemia: Young Hwangbo, M.D., Jae Young Jang, M.D., Jaejun Shim, M.D., Seok Ho Dong, M.D., Hyo Jong Kim, M.D., Byung Ho Kim, M.D., Young Woon Chang, M.D. and Rin Chang, M.D.; Korean J Gastrointest Endosc 2009;38(5):288-293. Published online May 30, 2009

Abstract PDF: Synchronous double malignancies of early gastric cancer and chronic myelogenous leukemia (CML) are very rare. There are few reports regarding the effect of the CML or imatinib on stomach cancer, and it is difficult to make a decision for the proper timing of treatment for early gastric cancer (EGC) in a patient with CML. A 56-year-old man was diagnosed with early gastric cancer. During the evaluation of his disease, he was also diagnosed as having Philadelphia chromosome positive chronic myleogenous leukemia. He started to take 400 mg of imatinib per day. Two weeks later, he underwent endoscopic submucosal dissection (ESD) for the early gastric cancer. Although there was a bleeding complication, complete resection was successfully performed. ESD is an effective treatment modality for EGC in CML patients, but physicians should keep a watchful eye for bleeding complications after the procedure. Further studies and more experience are needed to determine the proper timing of treatment for these patients. (Korean J Gastrointest Endosc 2009;38:288-293)

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Comparison of Endoscopic Forcep Biopsy and the Histopathologic Diagnosis after Endoscopic Submucosal Dissection: Young Dae Kim, M.D., Joo Young Cho, M.D., In Seop Jung, M.D., Bong Min Koh, M.D., Su Jin Hong, M.D., Chang Beom Ryu, M.D., Jin Oh Kim, M.D., Joon Seong Lee, M.D., Moon Sung Lee, M.D., So Young Jin, M.D.*, Chan Sup Shim, M.D. and Boo Sung Kim, M.D.; Korean J Gastrointest Endosc 2009;38(4):188-192. Published online April 30, 2009

Abstract PDF: Background
/Aims: The discrepancy of the histopathological diagnosis between endoscopic forcep biopsy, surgery and endoscopic mucosal resection (EMR), has been reported on in a previous study. We compared the results of endoscopic forcep biopsy and the histopathologic diagnosis after performing endoscopic submucosal dissection (ESD). Methods: We retrospectively reviewed 434 lesions for which we were able to compare the post-ESD histopathologic results with the endoscopic biopsy. Results: 1) Of the 14 lesions that showed chronic gastritis or atypia by endoscopic biopsy, 9 were diagnosed with carcinoma in situ or adenocarcinoma after ESD. 2) fifty one of 141 lesions that showed low grade dysplasia on the endoscopic biopsy were diagnosed with carcinoma in situ or adenocarcinoma after ESD. 3) Of the 60 lesions that showed high grade dysplasia on the endoscopic biopsy, 46 were diagnosis with carcinoma in situ or adenocarcinoma after ESD. Conclusions: The discrepancy of the histopathological diagnosis was found between ESD and forcep biopsy. In light of these results, if a lesion that is suspected to be EGC, although it is not diagnosed by endoscopic biopsy, then it should be confirmed by ESD. (Korean J Gastrointest Endosc 2009;38:188-192)

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A Case of Advanced Gastric Cancer and the First Symptom was a Skin Lesion: Sang Hyun Park, M.D., Sang Dae Lee, M.D., Tae Ung Lee, M.D., Hong Sun Son, M.D., Sang Jin Cho, M.D., Dong Il Byun, M.D., In Sik Park, M.D.* and Su Nam Lee, M.D.^†; Korean J Gastrointest Endosc 2009;38(2):90-93. Published online February 27, 2009

Abstract PDF: Cutaneous metastasis of internal malignancies is rare and the incidence of metastatic skin lesions as the first symptom of disease is only 0.8% for patients with all types of malignancies. Furthermore, cutaneous metastasis from advanced gastric cancer is exceedingly rare. A 43-year-old man presented with a single, symptomatic, erythematous nodule on the chest wall. A biopsy taken from the nodule showed an adenocarcinoma of the poorly differentiated type. An endoscopic examination and biopsy was done and these showed the same histologic findings. We reported here on this unusual case of advanced gastric cancer and the patient's first symptom was a skin lesion. (Korean J Gastrointest Endosc 2009;38:90-93)

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A Case of Synchronous Triple Early Gastric Cancer: Dong Han Im, M.D., Pyoung Rak Choi, M.D., Eun Ho Park, M.D., Jee Suk Lee, M.D., Seun Ja Park, M.D., Moo In Park, M.D., Won Moon, M.D. and Kyu Jong Kim, M.D.; Korean J Gastrointest Endosc 2009;38(1):34-37. Published online January 30, 2009

Abstract PDF: Multiple gastric cancers have several clinicopathologic characteristics that are different from those of solitary cancer and the incidence of multiple gastric cancers has recently been on the increase due to the development of diagnostic endoscopy, chromoscopy, and radiological examination. It is important to determine the proper surgical area after evaluating the synchronous multiple gastric cancer by performing closed endoscopy and radiological evaluation prior to surgery. Generally, elderly men have a relatively high incidence of multiple gastric cancers and the well differentiated type is most common. There have been reports on the diagnoses of multiple gastric cancers of elderly men and the well differentiated type, but there are no prior reports concerned with multiple gastric cancers of younger patients and the different pathologic differentiation. We experienced a case of synchronous multiple early gastric cancer of a younger man and this showed different pathologic differentiation. (Korean J Gastrointest Endosc 2009;38:34-37)

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